|
Rubeola IgG Antibody DMCL
|
Facility
|
IP
|
$123.00
|
|
|
Service Code
|
CPT 86765
|
| Hospital Charge Code |
8037799
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$86.10 |
| Max. Negotiated Rate |
$110.70 |
| Rate for Payer: Aetna of IA Commercial |
$110.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$110.70
|
| Rate for Payer: Cash Price |
$98.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$92.25
|
| Rate for Payer: Medical Associates Commercial |
$92.25
|
| Rate for Payer: Midlands Choice Commercial |
$86.10
|
| Rate for Payer: United Healthcare Commercial |
$110.70
|
|
|
Rubeola IgG Antibody DMCL
|
Facility
|
OP
|
$123.00
|
|
|
Service Code
|
CPT 86765
|
| Hospital Charge Code |
8037799
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$47.12 |
| Max. Negotiated Rate |
$110.70 |
| Rate for Payer: Aetna of IA Commercial |
$110.70
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$110.70
|
| Rate for Payer: Aetna of IA Medicare |
$70.11
|
| Rate for Payer: Amerigroup Medicaid |
$62.08
|
| Rate for Payer: Amerigroup Medicare |
$62.12
|
| Rate for Payer: Cash Price |
$98.40
|
| Rate for Payer: Cash Price |
$98.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$92.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$61.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$61.48
|
| Rate for Payer: Medical Associates Commercial |
$92.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$61.50
|
| Rate for Payer: Midlands Choice Commercial |
$86.10
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$62.42
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$62.39
|
| Rate for Payer: Oscar Health of IA Commercial |
$92.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$92.25
|
| Rate for Payer: United Healthcare Commercial |
$110.70
|
| Rate for Payer: United Healthcare Managed Medicare |
$72.57
|
| Rate for Payer: Wellmark IA HMO |
$47.12
|
| Rate for Payer: Wellmark IA PPO |
$51.83
|
|
|
sacubitril-valsartan 24 mg-26 mg Tab[VDMC]
|
Facility
|
OP
|
$44.14
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11856650
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$22.06 |
| Max. Negotiated Rate |
$39.73 |
| Rate for Payer: Aetna of IA Commercial |
$39.73
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$39.73
|
| Rate for Payer: Aetna of IA Medicare |
$25.16
|
| Rate for Payer: Amerigroup Medicaid |
$22.28
|
| Rate for Payer: Amerigroup Medicare |
$22.29
|
| Rate for Payer: Cash Price |
$35.31
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$33.10
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$22.07
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$22.06
|
| Rate for Payer: Medical Associates Commercial |
$33.10
|
| Rate for Payer: Medical Associates Managed Medicare |
$22.07
|
| Rate for Payer: Midlands Choice Commercial |
$30.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$22.40
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$22.39
|
| Rate for Payer: Oscar Health of IA Commercial |
$33.10
|
| Rate for Payer: Partners Health Alliance Commercial |
$33.10
|
| Rate for Payer: United Healthcare Commercial |
$39.73
|
| Rate for Payer: United Healthcare Managed Medicare |
$26.04
|
|
|
sacubitril-valsartan 24 mg-26 mg Tab[VDMC]
|
Facility
|
IP
|
$44.14
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
11856650
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$30.90 |
| Max. Negotiated Rate |
$39.73 |
| Rate for Payer: Aetna of IA Commercial |
$39.73
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$39.73
|
| Rate for Payer: Cash Price |
$35.31
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$33.10
|
| Rate for Payer: Medical Associates Commercial |
$33.10
|
| Rate for Payer: Midlands Choice Commercial |
$30.90
|
| Rate for Payer: United Healthcare Commercial |
$39.73
|
|
|
SALICYLATE
|
Facility
|
OP
|
$139.00
|
|
|
Service Code
|
CPT G0480
|
| Hospital Charge Code |
1503768
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$69.47 |
| Max. Negotiated Rate |
$125.10 |
| Rate for Payer: Aetna of IA Commercial |
$125.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$125.10
|
| Rate for Payer: Aetna of IA Medicare |
$79.23
|
| Rate for Payer: Amerigroup Medicaid |
$70.15
|
| Rate for Payer: Amerigroup Medicare |
$70.20
|
| Rate for Payer: Cash Price |
$111.20
|
| Rate for Payer: Cash Price |
$111.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$104.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$69.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$69.47
|
| Rate for Payer: Medical Associates Commercial |
$104.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$69.50
|
| Rate for Payer: Midlands Choice Commercial |
$97.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$70.54
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$70.50
|
| Rate for Payer: Oscar Health of IA Commercial |
$104.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$104.25
|
| Rate for Payer: United Healthcare Commercial |
$125.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$82.01
|
| Rate for Payer: Wellmark IA HMO |
$102.92
|
| Rate for Payer: Wellmark IA PPO |
$113.21
|
|
|
SALICYLATE
|
Facility
|
IP
|
$139.00
|
|
|
Service Code
|
CPT G0480
|
| Hospital Charge Code |
1503768
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$97.30 |
| Max. Negotiated Rate |
$125.10 |
| Rate for Payer: Aetna of IA Commercial |
$125.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$125.10
|
| Rate for Payer: Cash Price |
$111.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$104.25
|
| Rate for Payer: Medical Associates Commercial |
$104.25
|
| Rate for Payer: Midlands Choice Commercial |
$97.30
|
| Rate for Payer: United Healthcare Commercial |
$125.10
|
|
|
Salivary Gland Procedures
|
Facility
|
IP
|
$10,091.43
|
|
|
Service Code
|
MS-DRG 139
|
| Hospital Charge Code |
19
|
| Min. Negotiated Rate |
$9,945.17 |
| Max. Negotiated Rate |
$10,091.43 |
| Rate for Payer: Amerigroup Medicaid |
$10,042.68
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$9,945.17
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$10,091.43
|
|
|
saliva substitutes - Spr[VDMC]
|
Facility
|
IP
|
$32.12
|
|
|
Service Code
|
HCPCS A9155
|
| Hospital Charge Code |
12862338
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$22.48 |
| Max. Negotiated Rate |
$28.91 |
| Rate for Payer: Aetna of IA Commercial |
$28.91
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$28.91
|
| Rate for Payer: Cash Price |
$25.70
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$24.09
|
| Rate for Payer: Medical Associates Commercial |
$24.09
|
| Rate for Payer: Midlands Choice Commercial |
$22.48
|
| Rate for Payer: United Healthcare Commercial |
$28.91
|
|
|
saliva substitutes - Spr[VDMC]
|
Facility
|
OP
|
$32.12
|
|
|
Service Code
|
HCPCS A9155
|
| Hospital Charge Code |
12862338
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.05 |
| Max. Negotiated Rate |
$28.91 |
| Rate for Payer: Aetna of IA Commercial |
$28.91
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$28.91
|
| Rate for Payer: Aetna of IA Medicare |
$18.31
|
| Rate for Payer: Amerigroup Medicaid |
$16.21
|
| Rate for Payer: Amerigroup Medicare |
$16.22
|
| Rate for Payer: Cash Price |
$25.70
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$24.09
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$16.06
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$16.05
|
| Rate for Payer: Medical Associates Commercial |
$24.09
|
| Rate for Payer: Medical Associates Managed Medicare |
$16.06
|
| Rate for Payer: Midlands Choice Commercial |
$22.48
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$16.30
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$16.29
|
| Rate for Payer: Oscar Health of IA Commercial |
$24.09
|
| Rate for Payer: Partners Health Alliance Commercial |
$24.09
|
| Rate for Payer: United Healthcare Commercial |
$28.91
|
| Rate for Payer: United Healthcare Managed Medicare |
$18.95
|
|
|
salsalate 500 mg Tab [VDMC]
|
Facility
|
OP
|
$2.11
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10420104
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Aetna of IA Commercial |
$1.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.90
|
| Rate for Payer: Aetna of IA Medicare |
$1.20
|
| Rate for Payer: Amerigroup Medicaid |
$1.06
|
| Rate for Payer: Amerigroup Medicare |
$1.07
|
| Rate for Payer: Cash Price |
$1.69
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.58
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.06
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.05
|
| Rate for Payer: Medical Associates Commercial |
$1.58
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.06
|
| Rate for Payer: Midlands Choice Commercial |
$1.48
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1.07
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$1.07
|
| Rate for Payer: Oscar Health of IA Commercial |
$1.58
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.58
|
| Rate for Payer: United Healthcare Commercial |
$1.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$1.24
|
|
|
salsalate 500 mg Tab [VDMC]
|
Facility
|
IP
|
$2.11
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10420104
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Aetna of IA Commercial |
$1.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.90
|
| Rate for Payer: Cash Price |
$1.69
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.58
|
| Rate for Payer: Medical Associates Commercial |
$1.58
|
| Rate for Payer: Midlands Choice Commercial |
$1.48
|
| Rate for Payer: United Healthcare Commercial |
$1.90
|
|
|
SARS-CoV-2 (COVID-19) 12YR+ mRNA-LNP vaccine (cvx 312) preservative-free 50 mcg/0.5 mL Sus
|
Facility
|
IP
|
$149.50
|
|
|
Service Code
|
HCPCS 91322
|
| Hospital Charge Code |
26766683
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$104.65 |
| Max. Negotiated Rate |
$134.55 |
| Rate for Payer: Aetna of IA Commercial |
$134.55
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$134.55
|
| Rate for Payer: Cash Price |
$119.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$112.12
|
| Rate for Payer: Medical Associates Commercial |
$112.12
|
| Rate for Payer: Midlands Choice Commercial |
$104.65
|
| Rate for Payer: United Healthcare Commercial |
$134.55
|
|
|
SARS-CoV-2 (COVID-19) 12YR+ mRNA-LNP vaccine (cvx 312) preservative-free 50 mcg/0.5 mL Sus
|
Facility
|
OP
|
$149.50
|
|
|
Service Code
|
HCPCS 91322
|
| Hospital Charge Code |
26766683
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$74.72 |
| Max. Negotiated Rate |
$134.55 |
| Rate for Payer: Aetna of IA Commercial |
$134.55
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$134.55
|
| Rate for Payer: Aetna of IA Medicare |
$85.22
|
| Rate for Payer: Amerigroup Medicaid |
$75.45
|
| Rate for Payer: Amerigroup Medicare |
$75.50
|
| Rate for Payer: Cash Price |
$119.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$112.12
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$74.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$74.72
|
| Rate for Payer: Medical Associates Commercial |
$112.12
|
| Rate for Payer: Medical Associates Managed Medicare |
$74.75
|
| Rate for Payer: Midlands Choice Commercial |
$104.65
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$75.87
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$75.83
|
| Rate for Payer: Oscar Health of IA Commercial |
$112.12
|
| Rate for Payer: Partners Health Alliance Commercial |
$112.12
|
| Rate for Payer: United Healthcare Commercial |
$134.55
|
| Rate for Payer: United Healthcare Managed Medicare |
$88.20
|
|
|
SARS-CoV-2 (COVID-19) 6M-11YR mRNA-LNP vaccine (cvx 311) preservative-free 25 mcg/0.25 mL Sus
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
HCPCS 91321
|
| Hospital Charge Code |
26766930
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$58.80 |
| Max. Negotiated Rate |
$75.60 |
| Rate for Payer: Aetna of IA Commercial |
$75.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$75.60
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$63.00
|
| Rate for Payer: Medical Associates Commercial |
$63.00
|
| Rate for Payer: Midlands Choice Commercial |
$58.80
|
| Rate for Payer: United Healthcare Commercial |
$75.60
|
|
|
SARS-CoV-2 (COVID-19) 6M-11YR mRNA-LNP vaccine (cvx 311) preservative-free 25 mcg/0.25 mL Sus
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
HCPCS 91321
|
| Hospital Charge Code |
26766930
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$41.98 |
| Max. Negotiated Rate |
$75.60 |
| Rate for Payer: Aetna of IA Commercial |
$75.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$75.60
|
| Rate for Payer: Aetna of IA Medicare |
$47.88
|
| Rate for Payer: Amerigroup Medicaid |
$42.39
|
| Rate for Payer: Amerigroup Medicare |
$42.42
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$63.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$42.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$41.98
|
| Rate for Payer: Medical Associates Commercial |
$63.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$42.00
|
| Rate for Payer: Midlands Choice Commercial |
$58.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$42.63
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$42.60
|
| Rate for Payer: Oscar Health of IA Commercial |
$63.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$63.00
|
| Rate for Payer: United Healthcare Commercial |
$75.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$49.56
|
|
|
SARS-CoV-2 (COVID-19) BioFire
|
Facility
|
OP
|
$338.00
|
|
|
Service Code
|
CPT U0004 CS
|
| Hospital Charge Code |
8789912
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$168.93 |
| Max. Negotiated Rate |
$304.20 |
| Rate for Payer: Aetna of IA Commercial |
$304.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$304.20
|
| Rate for Payer: Aetna of IA Medicare |
$192.66
|
| Rate for Payer: Amerigroup Medicaid |
$170.59
|
| Rate for Payer: Amerigroup Medicare |
$170.69
|
| Rate for Payer: Cash Price |
$270.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$253.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$169.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$168.93
|
| Rate for Payer: Medical Associates Commercial |
$253.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$169.00
|
| Rate for Payer: Midlands Choice Commercial |
$236.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$171.54
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$171.43
|
| Rate for Payer: Oscar Health of IA Commercial |
$253.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$253.50
|
| Rate for Payer: United Healthcare Commercial |
$304.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$199.42
|
|
|
SARS-CoV-2 (COVID-19) BioFire
|
Facility
|
IP
|
$338.00
|
|
|
Service Code
|
CPT U0004 CS
|
| Hospital Charge Code |
8789912
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$236.60 |
| Max. Negotiated Rate |
$304.20 |
| Rate for Payer: Aetna of IA Commercial |
$304.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$304.20
|
| Rate for Payer: Cash Price |
$270.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$253.50
|
| Rate for Payer: Medical Associates Commercial |
$253.50
|
| Rate for Payer: Midlands Choice Commercial |
$236.60
|
| Rate for Payer: United Healthcare Commercial |
$304.20
|
|
|
saxagliptin 5 mg Tab [VDMC]
|
Facility
|
OP
|
$52.72
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10420173
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.35 |
| Max. Negotiated Rate |
$47.45 |
| Rate for Payer: Aetna of IA Commercial |
$47.45
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$47.45
|
| Rate for Payer: Aetna of IA Medicare |
$30.05
|
| Rate for Payer: Amerigroup Medicaid |
$26.61
|
| Rate for Payer: Amerigroup Medicare |
$26.62
|
| Rate for Payer: Cash Price |
$42.18
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$39.54
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$26.36
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$26.35
|
| Rate for Payer: Medical Associates Commercial |
$39.54
|
| Rate for Payer: Medical Associates Managed Medicare |
$26.36
|
| Rate for Payer: Midlands Choice Commercial |
$36.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$26.76
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$26.74
|
| Rate for Payer: Oscar Health of IA Commercial |
$39.54
|
| Rate for Payer: Partners Health Alliance Commercial |
$39.54
|
| Rate for Payer: United Healthcare Commercial |
$47.45
|
| Rate for Payer: United Healthcare Managed Medicare |
$31.10
|
|
|
saxagliptin 5 mg Tab [VDMC]
|
Facility
|
IP
|
$52.72
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10420173
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$36.90 |
| Max. Negotiated Rate |
$47.45 |
| Rate for Payer: Aetna of IA Commercial |
$47.45
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$47.45
|
| Rate for Payer: Cash Price |
$42.18
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$39.54
|
| Rate for Payer: Medical Associates Commercial |
$39.54
|
| Rate for Payer: Midlands Choice Commercial |
$36.90
|
| Rate for Payer: United Healthcare Commercial |
$47.45
|
|
|
SCIATIC NERVE BLOCK CHARGE
|
Professional
|
Both
|
$342.00
|
|
|
Service Code
|
CPT 64445
|
| Hospital Charge Code |
8059065
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$65.85 |
| Max. Negotiated Rate |
$239.40 |
| Rate for Payer: Aetna of IA Medicare |
$65.85
|
| Rate for Payer: Amerigroup Medicaid |
$68.09
|
| Rate for Payer: Cash Price |
$273.60
|
| Rate for Payer: Cash Price |
$273.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$79.02
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$67.17
|
| Rate for Payer: Medical Associates Commercial |
$125.12
|
| Rate for Payer: Medical Associates Managed Medicare |
$65.85
|
| Rate for Payer: Midlands Choice Commercial |
$239.40
|
| Rate for Payer: Oscar Health of IA Commercial |
$113.92
|
| Rate for Payer: Partners Health Alliance Commercial |
$98.78
|
|
|
scopolamine 1.5 mg Transderm ER Film [VDMC]
|
Facility
|
IP
|
$29.60
|
|
|
Service Code
|
NDC 10019-0553-04
|
| Hospital Charge Code |
10420242
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.72 |
| Max. Negotiated Rate |
$26.64 |
| Rate for Payer: Aetna of IA Commercial |
$26.64
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$26.64
|
| Rate for Payer: Cash Price |
$23.68
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$22.20
|
| Rate for Payer: Medical Associates Commercial |
$22.20
|
| Rate for Payer: Midlands Choice Commercial |
$20.72
|
| Rate for Payer: United Healthcare Commercial |
$26.64
|
|
|
scopolamine 1.5 mg Transderm ER Film [VDMC]
|
Facility
|
OP
|
$29.60
|
|
|
Service Code
|
NDC 10019-0553-04
|
| Hospital Charge Code |
10420242
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.79 |
| Max. Negotiated Rate |
$26.64 |
| Rate for Payer: Aetna of IA Commercial |
$26.64
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$26.64
|
| Rate for Payer: Aetna of IA Medicare |
$16.87
|
| Rate for Payer: Amerigroup Medicaid |
$14.94
|
| Rate for Payer: Amerigroup Medicare |
$14.95
|
| Rate for Payer: Cash Price |
$23.68
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$22.20
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$14.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$14.79
|
| Rate for Payer: Medical Associates Commercial |
$22.20
|
| Rate for Payer: Medical Associates Managed Medicare |
$14.80
|
| Rate for Payer: Midlands Choice Commercial |
$20.72
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$15.02
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$15.01
|
| Rate for Payer: Oscar Health of IA Commercial |
$22.20
|
| Rate for Payer: Partners Health Alliance Commercial |
$22.20
|
| Rate for Payer: United Healthcare Commercial |
$26.64
|
| Rate for Payer: United Healthcare Managed Medicare |
$17.46
|
|
|
SCREW 2.2MMX16MM
|
Facility
|
OP
|
$198.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8814832
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$98.96 |
| Max. Negotiated Rate |
$178.20 |
| Rate for Payer: Aetna of IA Commercial |
$178.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$178.20
|
| Rate for Payer: Aetna of IA Medicare |
$112.86
|
| Rate for Payer: Amerigroup Medicaid |
$99.93
|
| Rate for Payer: Amerigroup Medicare |
$99.99
|
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$148.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$99.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$98.96
|
| Rate for Payer: Medical Associates Commercial |
$148.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$99.00
|
| Rate for Payer: Midlands Choice Commercial |
$138.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$100.48
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$100.43
|
| Rate for Payer: Oscar Health of IA Commercial |
$148.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$148.50
|
| Rate for Payer: United Healthcare Commercial |
$178.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$116.82
|
|
|
SCREW 2.2MMX16MM
|
Facility
|
IP
|
$198.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8814832
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$138.60 |
| Max. Negotiated Rate |
$178.20 |
| Rate for Payer: Aetna of IA Commercial |
$178.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$178.20
|
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$148.50
|
| Rate for Payer: Medical Associates Commercial |
$148.50
|
| Rate for Payer: Midlands Choice Commercial |
$138.60
|
| Rate for Payer: United Healthcare Commercial |
$178.20
|
|
|
SCREW 2.2MMX20MM
|
Facility
|
OP
|
$198.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
8814834
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$98.96 |
| Max. Negotiated Rate |
$178.20 |
| Rate for Payer: Aetna of IA Commercial |
$178.20
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$178.20
|
| Rate for Payer: Aetna of IA Medicare |
$112.86
|
| Rate for Payer: Amerigroup Medicaid |
$99.93
|
| Rate for Payer: Amerigroup Medicare |
$99.99
|
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$148.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$99.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$98.96
|
| Rate for Payer: Medical Associates Commercial |
$148.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$99.00
|
| Rate for Payer: Midlands Choice Commercial |
$138.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$100.48
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$100.43
|
| Rate for Payer: Oscar Health of IA Commercial |
$148.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$148.50
|
| Rate for Payer: United Healthcare Commercial |
$178.20
|
| Rate for Payer: United Healthcare Managed Medicare |
$116.82
|
|
